DR SAMEER S

APPROACH TO RECURRENT ABDOMINAL PAIN IN CHILDREN

Clinical Definitions

Source:Hyams et.al 1996.

Acute Abdominal Pain:Less than 4-6 week ,sub acute (less than

12 weeks)Single episode, self limited and treatableEpisodic localized pain, sharp, stabbing

Chronic Abdominal Pain:Pain of at least 3 months duration; Long

lasting, intermittent or constant that is functional ororganic (disease)

Recurrent abdominal pain (Apley and Naish, 1958)

Waxes and wanes 3 episodes in 3 months Severe enough to affect activities No organic cause

Functional Abdominal Pain:Abdominal Pain without evidence of disease/pathologic

process. Can manifest with symptoms typical of functional dyspepsia, irritable bowel syndrome, abdominal migraine or functional abdominal pain syndrome.

The American Academy of Pediatrics (AAP) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines for the evaluation and treatment of children with chronic abdominal pain recommend that:

the term "recurrent abdominal pain" should not be used as a synonym for functional, psychological, or stress-related abdominal pain . Functional abdominal pain, which is the most common cause of chronic abdominal pain, is a specific diagnosis that must be distinguished from other causes of abdominal pain (eg, anatomic, infectious, inflammatory, metabolic) Source: AAP, 2005

Abdominal pain: evidence-based data

Incidence 5 % of patients presenting to the pediatric clinic and ED (2 – 12 years

old, <72 hours duration) 1% of patients with abdominal pain had surgical intervention 84 % of patients were diagnosed to have

URI and/or Otitis Media Pharyngitis Viral syndrome Abdominal pain or uncertain etiology Gastroenteritis Acute febrile illness Sickle cell anemia H S Purpura 7.4% return visit 1.7% hospitalized

ABDOMINAL PAIN: EVIDENCE-BASED DATA

Associated symptoms

Fever

Vomiting

Decreased appetite

Cough

Headache

Sorethroat

(NOT GOOD)

1/3 of them presenting with Abdominal Pain get no specific diagnosis!!!

Most Common Causes in the ED(ACUTE)

Non-specific abd pain 34%

Appendicitis 28%

Biliary tract dz 10%

Obstruction 4%

Gynaecological disease 4%

Pancreatitis 3%

Renal colic 3%

Perforated ulcer 3%

Cancer 2%

Diverticular dz 2%

Other 6%

Age

Type of Pain

Visceral

Parietal

Refered

Visceral Pain

Stretching of nerve fibresof walls or capsules of organs

Crampy

Dull

Achy

Often unable to lie

Bilateral innervation

Parietal Pain

Parietal peritoneum irritated

Usually anterior abdominal wall

Localised to the dermatome superficial to the site of painful stimulus

Localized

Tenderness,Guarding,Ridigity,Rebound as peritonities

Classification of Pain In Abdomen

A) Organic and Non-organic

B)Etiological

C) Age

D) Location/ quadrant

(B)Etiological Classification

Infections: Viruses or bacteria. Food-related: Food introlarance,food allergies,

eating excessive food, or gas production – any of these can cause bloating and temporary discomfort, rapid after eating.

Poisoning: This can range from simple problems (such as eating soap) to more serious issues like swallowing iron pills, magnets, coins, botulism from spoiled food, or an overdose of medications (such as acetaminophen poisoning [Tylenol]).

Surgical problems: These includeappendicitis or blockage of the bowels.

Medical

Genitourinary causesUrinary tract infectionUrinary calculiDysmenorrheaMittelschmerzPelvic inflammatory diseaseThreatened abortion

Ectopic pregnancyOvarian/testicular torsionEndometriosisHematocolpos

Liver, spleen, and biliary tract disordersHepatitisCholecystitisCholelithiasisSplenic infarctionRupture of the spleenPancreatitis

• GASTROINTESTINALGastroenteritisAppendicitisMesentric lymphadenitisConstipationAbdominal trumaIntestinal obstPeritonitis

• Metabolic disordersDiabetic ketoacidosisHypoglycemiaPorphyriaAcute adrenal insufficiencyHematologic disordersSickle cell anemiaHenoch-Schönlein purpuraHemolytic uremic syndrome

• Pulmonary causesPneumoniaDiaphragmatic

• Drugs and toxinsErythromycinSalicylatesLead poisoningVenoms

• Miscellaneous causesAbdominal epilepsyGilberts syndromeFamilial Mediterranean feverSickle cell crisisLead poisoningHSPAngioneurotic edemaAcute intermittent porphyria

(C)Classification as per age

(D) Classification as per Quadrant

HISTORY

Pain: Location, Quality, Severity, Onset, Duration Modifying factors Change over time R your child eating poorly Poor eating

GI symptoms

Nausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stools

GU symptoms

Dysuria, frequency, urgency, hematuria, incontinence

Gyn symptoms

Vaginal discharge, vaginal bleeding

General

Fever, lightheadedness,cough,cold

And don’t forget the history

GI Past abdominal surgeries, h/o GB disease, ulcers;

FamHx IBD GU Past surgeries, h/o kidney stones, pyelonephritis, UTI

Gyn Last menses, sexual activity, contraception, h/o PID or

STDs, h/o ovarian cysts, CVS h/o heart disease, CHF, Other medical history DM, SCD, Allergies, Recurrent chest infection

Medications NSAIDs, H2 blockers, PPIs, immunosuppression,

Moving on to the Physical Exam

General Pallor, diaphoresis, general appearance, level of

distress or discomfort, is the patient lying still or moving around in the bed. Drawing legs up toward to belly

Ht , weight,Head Circumference (Abnormal growth and/or involuntary weight loss)

Signs of delyed Puberty

Vital Signs

Abdominal Findings

Guarding Voluntary

Contraction of abdominal musculature in anticipation of palpation

Diminish by having patient flex knees

Involuntary Reflex spasm of abdominal muscles rigidity Suggests peritoneal irritation

Rebound Present in 1 of 4 patients without peritonitis

Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis Rovsing’s sign in appendicitis

Rectal exam Most important Gross blood or melena indicates a GI Bleeding Examination of Genitalia

Other system

R/S - Pnemonia

CVS –CHD,Murmur

Pelvic Exam-Vaginal disharge ,Plapable masses

Diagnostic Tools

Rome III Criteria Essential Investigations : according to symptoms e.g.- CBC- U A , Stool exam- LDG, Amylase ,lipase- Ultrasound- Barium study- Gastric emptying time test ,Intestinal transit time

,Colonic transit time test- Hydrogen breath test: lactose ,lactulose,glucose- Endoscopy- Skin Prick test- Urea Breath test

Imaging

Depends what you are looking for! Abdominal series

3 views: upright chest, flat view of abdomen, upright view of abdomen

Limited utility: restrict use to patients with suspected obstruction or free air

Ultrasound Good for diagnosing, Good for pelvic pathology

CT abdomen/pelvis Non-contrast for free air, renal colic,, bowel obstruction Contrast study for abscess, infection, inflammation, unknown cause

MRI Most often used when unable to obtain CT due to contrast issue

Recommendation of North American Society for Pediatric Gastroenterology,

Hepatology and Nutrition

Additional diagnostic evaluation is not required in children without alarm symptoms

Testing may be carried out to reassure children and theirparents

What are the predictive values of diagnostic tests?

There is no evidence to suggest that the use ofultrasonographic examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yield of organic disease .

There is little evidence to suggest that the use of endoscopy and biopsy in the absence of alarm symptoms has a significant yield of organic disease .

There is insufficient evidence to suggest that the use ofesophageal pH monitoring in the absence of alarmsymptoms has a significant yield of organic disease .

PITFALLS:

• Incomplete exams (rectals, pelvics and genital exams)

• Incomplete histories

• Missing abnormal vitals

• Relying on labs

• Relying on imaging

• Not performing serial exams

• Infant, the pregnant, altered or psychiatric patients

• “Constipation” “GERD” “Gastroenteritis” and “UTI”

Simple advice & Health Education

Home Care

Most of the time, you can wait for your child to get better and use home care remedies. If you are worried or your child’s pain is getting worse or lasts longer than 24 hours, call your health care provider.

Offer sips of water or other clear fluids.

Suggest that your child try to pass stool.

Avoid solid foods for a few hours. Then try small amounts of mild foods such as rice, applesauce, or crackers.

Do not give your child foods or drinks that are irritating to the stomach.

Avoid:Caffeine Carbonated beverages,Citrus,Dairy productsFried, or greasy foods,High-fat foods,Tomato products

Do not give aspirin, ibuprofen, acetaminophen without first asking your child's health care provider.

To prevent many types of abdominal pain:

Avoid fatty or greasy foods.

Drink plenty of water each day.

Eat small meals more often.

Exercise regularly.

Limit foods that produce gas.

Make sure that meals are well-balanced and high in fiber. Eat plenty of fruits and vegetables.

WHEN TO CONTACT A MEDICAL PROFESSIONAL

Abdominal pain does not go away in 24 hours

Is a baby younger than 3 months and has diarrhea or vomiting

Is unable to pass stool, especially if the child is also vomiting

Is vomiting blood or has blood in the stool (especially if the blood is maroon or dark, tarry black)

Has sudden, sharp abdominal pain

Has a rigid, hard belly

Has had a recent injury to the abdomen

Is having trouble breathing

Abdominal pain that lasts 1 week or longer, even if it comes and goes.

A burning sensation during urination

Diarrhea for more than 2 days

Vomiting for more than 12 hours

Fever over 100.4 degrees F

Poor appetite for more than 2 days

Unexplained weight loss

DICTUM

All child of non-verbal age presenting with Significant

Pain should be considered to have abdominal pathological

until proven otherwise.

HOW TO APPROACH

Non Organic Cause

Rome III criteria, 2006

Functional dyspepsia

Irritable bowel syndrome

Functional abdominal pain

Functional abdominal pain syndrome

Abdominal migraine

- No evidence of an inflammatory, anatomical, metabolic or neoplastic process

- Criteria fulfilled at least once a week for at least two months before diagnosis

Dyspepsia = Epigastric discomfort

14 year old boy with two month history Bothersome post-prandial fullness Early satiation Epigastric pain Epigastric burning

Normal physical examination Normal screening labs CBC Hepatobiliary enzyme tests IgA and tTG Lipase or amylase Stool for occult blood

What should we do next?

Recommend endoscopy when

Vomiting or weight loss

Positive screening test

Low yield test

Often, does not relieve anxiety

Should we do radiologic testing?

Obstructive symptoms or signs

Should we do testing for H. pylori?

Family history

Acute symptoms

How effective is therapy for dyspepsia?

Proton pump inhibitor < 50% response

No increase in response to high doses

Anti-helicobacter 10-15% response

No improvement with repeated courses

Prokinetic agents Side effects frequent

Antispasmodics No benefit

Antidepressants No benefit

Irritable Bowel Syndrome

Abdominal discomfort or pain associated with 2 or more of the following at least 25% of the time Improvement with

defecation Onset associated with a

change in stool frequency Onset associated with a

change in stool consistency

No evidence of another disorder

Present for two months or more

What is effective therapy for IBS?

Dietary changes

Lactose restriction

Gluten restriction

Medications

Loperamide

Low dose TCA

Psychosocial support

Most effective

No side effects

Fiber supplements

Lactose restriction Vitamin D restriction

Low calcium intake

Oral antibiotics

Anticholinergics

Probiotics

What is the role of gluten restriction?

Gluten sensitive enteropathy = celiac disease. Eat a gluten free diet.

Gluten sensitivity or intolerance.

GI symptoms associated with gluten intake

Early age of onset.

Functional abdominal pain syndrome

1. Continuous or nearly continuous abdominal pain

2. Little to no relationship of pain with eating, defecation, or menses

3. Some loss of daily functioning

4. The pain is not feigned (e.g., malingering)

5. Does not fit another functional gastrointestinal disorder

6. Duration = prior last 2 months with symptom onset at least 6 months before

Paroxysmal episodes of intense, acute periumbilical pain that lasts for one or more hours

Intervening periods of usual health lasting weeks to months

The pain interferes with normal activities The pain is associated with two or more of the

following:- Anorexia- Nausea- Vomiting- Headache- Photophobia- PallorCriteria fulfilled two or more times in the preceding 12

months

ABDOMINAL MIGRAINE

Treatment

Deal with psychological factors

Educate the family (an important part of treatment)

Focus on return to normal functioning rather than on the complete disappearance of pain

Best prescribe drugs judiciously as part of amultifaceted, individualised approach, to relievesymptoms and disability

Pharmacologic treatment approach

Medicines:

Acid lowering agents

Mucoprotective drugs

Motility regulators

Laxatives

Analgesics

Probiotics

Gas adsorbants

Dietary and life style change

Psychotherapy

Treatment of Acid-related disorders H2-receptor Antagonists:Ranitidine (2-4 mg/kg/d up to 150 mg bid),Famotidine (1-1.2 mg/kg/d up to 20 mg bid) PPI:Omeprazole (0.8 mg/kg/d;effective dose range

of 0.3-3.3 mg/kg/d),Lansoprazole (0.8 mg/kg/d) Cytoprotective Agents:Sucralfate(40-80 mg/kg/d up to 1 g qid)Rabemipride ( 1 x 3 )

Abdominal Pain Clinical Pearls

Significant abdominal tenderness should never be attributed to gastroenteritis

Incidence of gastroenteritis in the Older child are very low Always perform genital examinations when lower abdominal pain is

present – in males and females, in young and old Aways perform Rectal Examination Bilious vomiting consider abdominal pathology unless until proved Severe pain should be taken as an indicator of serious disease Pain awakening the patient from sleep should always be considered

signficant Sudden, severe pain suggests serious disease Pain almost always precedes vomiting in surgical causes; converse is

true for most gastroenteritis and NSAP A lack of free air on a chest xray does NOT rule out perforation Signs and symptoms of PUD, gastritis, reflux and nonspecific

dyspepsia have significant overlap.

Thank you